Bunionectomy

PROCEDURE IN DETAIL:  The patient was prepped and draped in the usual aseptic manner.  Anesthesia was obtained by injection of local anesthetic as a regional block to the right forefoot.  Hemostasis was obtained by application of a sterile Morton's elastic bandage to the right foot and ankle.  A longitudinal incision approximately 8 cm in length was performed over the dorsomedial aspect of the right first MPJ, medial to the extensor hallucis longus tendon.  The incision was deepened and subcutaneous tissues were divided, dissected and retracted.  The capsular structure of the first MPJ was well exposed.  The capsular structure was incised with an inverted-L capsular incision at the dorsal and medial aspects of the first MPJ.  The capsular structure was dissected free from underlying osseous tissue and retracted proixmalward.  The greatly hypertrophied medial and dorsal aspects of the first metatarsal head were resected with osteotome and mallet, and smoothed with rongeur and rasp.  A loose osseous body and exostosis were located at the dorsolateral aspect of the right first metatarsal head.  This was resected and removed with bone cutting rongeur and rasp.  The site was further dissected laterally into the first interspace, where the contracted tendon of the adductor hallucis was identified, transected and released from its contracted insertion into the lateral plantar base of the proximal phalanx of the hallux.  The fibular sesamoid was mobilized through dissection.  The capsular structure was lengthened and relieved of contracture through dissection.  The extensor hallucis brevis tendon was lengthened through Z-plasty lengthening.  Contractures on the lateral aspect of the extensor hallucis longus tendon were freed through dissection.  The site was flushed well repeatedly.  The inverted-L capsular incision was reapproximated and closed in a good balanced position with simple interrupted sutures of 3-0 Vicryl.  The first and second metatarsals were stabilized with pursestring sutures of 2-0 Vicryl.  The hallux was positioned well out of its lateral deviation and into a more normal position.  Subcutaneous tissues were closed with simple interrupted sutures of 4-0 Vicryl.  The skin was closed with a continuous running subcuticular suture of 4-0 Vicryl.

Carpal Tunnel Release

SUMMARY:  The procedure was performed in the supine position.  The patient was prepped and draped in the usual fashion.  A 1-cm interthenar crease incision was made and carried through the palmar aponeurosis to the transverse carpal ligament.  The transverse carpal ligament was incised, revealing the median nerve beneath.  The median nerve was identified and carefully protected using a lighted fiberoptic right-angle retractor as the transverse carpal ligament was divided distally to its terminal extent, then proximally well into the volar forearm until it was entirely released.  The Esmarch bandage around the proximal forearm as released after 20 minutes.  Hemostasis was assured.  The skin was closed with 4-0 nylon horizontal mattress sutures.  Sterile dressings were applied.

PROCEDURE IN DETAIL:  The patient was placed on the operating table in supine position and general anesthesia was administered.  The left hand and wrist were prepped and draped in a sterile manner.  A tourniquet was inflated about the left upper arm.  A transverse incision was made over the volar aspect of the wrist and dissection was carried through subcutaneous tissues, exposing the deep volar fascia of the forearm.  A flap was created in the fascia, allowing access to the carpal tunnel. Dilators were passed distally beneath the transverse carpal ligament.  A synovial elevator was utilized to clean synovial tissue from the deep surface of the ligament.   The endoscopic carpal tunnel device was inserted and the deep surface of the ligament was visualized.  The ligament was divided longitudinally.  The carpal tunnel release device was removed and the wound was closed with running subcuticular 4-0 Prolene suture.  The surgical site was infiltrated with 0.5% plain Marcaine to provide postoperative pain relief.  A sterile bandage was placed about the hand and wrist.  Circulation to the hand was good after tourniquet release.  The patient tolerated the procedure well and was taken to recovery in good condition.

Toe Arthroplasty
PROCEDURE IN DETAIL:  The patient was prepped and draped in the usual aseptic manner.  Anesthesia was obtained by injection of local anesthetic as a regional block to the left forefoot.  Hemostasis was obtained by application of a sterile Morton's elastic bandage to the left foot and ankle.  Two longitudinal semi-elliptical converging incisions were performed over the dorsal aspect of the left second toe centered on the proximal interphalangeal joint.  The incisions were deepened.  Subcutaneous tissues were divided, dissected and retracted, and intervening skin was removed.  The site was further dissected medially and laterally.  Subcutaneous and skin were retracted well.  The proximal IPJ was exposed.  The capsular structure was incised transversely medially and laterally, and medial and lateral collateral ligaments were incised and freed.  Further capsular structures were dissected free proximalward and retracted proximalward.  The greatly hypertrophied proximal phalangeal head was well exposed and was resected at the surgical neck with bone cutting forceps.  This was removed.  The stump was smoothed with bone cutting rongeur.  The site was flushed well repeatedly.  The capsular structure was reapproximated and closed, and a hinge joint formed with simple interrupted sutures of 4-0 Vicryl.  Subcutaneous tissues were reapproximated and closed with a simple interrupted suture of 4-0 Vicryl, and the skin was closed with a continuous running subcuticular suture of 4-0 Vicryl.

Total Knee Replacement

PROCEDURE IN DETAIL:  Prior to coming to the operating room, the patient had an epidural cannula inserted and epidural anesthesia administered.  He was experiencing good anesthesia on arrival in the operating room.  On the operating table, the right lower extremity was prepped and draped routinely, and exsanguinated with an Esmarch bandage.  A pneumatic tourniquet was inflated to 250 mmHg.  A straight longitudinal anterior incision was made. The joint was opened through a medial parapatellar incision.  The patella was everted and dislocated laterally.  The fat pad was excised.  There was severe wear of the medial femoral condyle and medial patella with bone on bone articulation.  A medial subperiosteal release was done on the proximal tibia. A large drill hole was placed between the femoral condyles into the medullary canal of the femur.  The first guide was positioned by driving its long central rod down this drill hole, carefully holding it in position, then fixing it with pins.  This was used to cut away the anterior surface of the femoral condyles.  The next cutting guide was placed on the cut anterior surface and connected to the previous guide and to the femur.  It was used to cut away the distal surfaces of the femoral condyles.  A femoral finishing block was applied and fixed with two smooth pins and two large screws.  It was used to cut away the posterior surface of the femoral condyles, to bevel the posterior corner, to trim the already cut anterior surface, and bevel the anterior corner.  It was also used to cut an anterior central slot out of the femur and to drill one large drill hole into each femoral condyle, thus completing preparation of the femur.  The tibial guide was positioned with a large spring distally and multiple pins proximally.  It was used to cut away the articular surfaces of the tibia, leaving a good flat cancellous surface.  The tibia was sized and the correct trial size was placed in place and held with pins.  It was used with a guide to drill a large drill hole into the tibial medullary canal and to cut lateral slots in the proximal tibia for the prosthesis.  Trial prostheses were placed until a good fit was found and it could be carried through a good range of motion.  The patella was then reamed using a patella reamer down to a good flat patellar surface.  Using a drill, three anchor holes were drilled into the patella.  Trial prostheses were inserted and the patella was carried through a range of motion.  With the prostheses in place, the knee appeared to be stable with excellent range of motion.  The trial prostheses were removed.  The knee was irrigated copiously with saline, Garamycin and Bacitracin.  The bony surfaces were dried thoroughly.  Methyl methacrylate had been mixed.  When it was at the proper consistency, it was placed in the knee and used to fix the tibial base plate, the femoral prosthesis and the patella prosthesis in place.  The tibial articular surface was snapped onto the base plate.  Excess cement was removed while it was still soft.  A clamp held the patella in place.  The knee was held in full extension with pressure upon the foot.  After hardening of the cement, the knee could be carried through an excellent range of motion and there was good stability.  The wound was again irrigated with antibiotic solution and suctioned dry.  A large blood recovery tube was placed in the knee.  The knee was repaired by repairing the quadriceps tendon and joint capsule with running and interrupted #1 Dexon suture.  The subcutaneous tissue was closed with interrupted 0 Vicryl, and the skin was closed with staples.  The knee was dressed and the tourniquet was deflated.  Prompt circulation returned.  The patient tolerated the procedure well and left the operating room in good condition